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Memphis: Mapping and Hotspotting

Mapping Assets

Case Study: Memphis Participatory Mapping and Hotspotting Methodology

scratch maps memphisMethodist Le Bonheur’s (MLH) Participatory Mapping and Hotspotting Methodology demonstrates the impact of place-based population health management, shared ownership for community health investment and the data collection/metrics to support the investment.

Memphis’ poorest zip code is 38109. Its 98% African-American residents experience a greater share of cardiovascular and renal disease, diabetes, and other conditions that lead to frequent hospitalizations and readmissions than any other in the city. Poor housing, unremitting stress and violence add to this chronic co-morbidity cocktail. MLH rates of readmissions, inappropriate emergency department use and charity care writeoffs are concentrated in this zip code, with $6.3 million spent there alone in 2010. Using technical hotspotting, MLH tracked these patients to the Memphis neighborhood called ‘Riverview Kansas.’

To improve community health and decrease inappropriate hospital utilization, MLH turned to one of the region’s greatest health ‘assets’— the Congregational Health Network (CHN)—a community partnership program based on a covenant relationship with over 500 congregations.

One CHN partner in 38109 is Rev. James Kendrick, whose fledging nonprofit Health Watch Urban Ministries renovates blighted housing, offers life and job skills training, and transports residents of these tough neighborhoods. Their aim is ‘building people,’ not infrastructure.

Since April 2012, MLH leaders and Kendrick have hosted active listening sessions with residents and clergy in 38109 to ‘co-create’ a plan to improve community health and hospital use. MLH combines this ‘high-touch’ relationship and capacity building—they call it ‘participatory hotspotting’—with its internal GIS research. A recent CIGNA community grant award allows them to micro-grant funds to clergy and Health Watch to further these efforts.

‘Ms. Mamie,’ an uninsured 61-year-old, two years post cerebrovascular accident (CVA), lives in a burned-out apartment complex in 38109. MLH provided stroke care, but she remains dysarthric from her stroke and is vulnerable to crime in her area. Health Watch is helping renovate her complex, while Pastor Kendrick and CHN developed a relationship with Mamie, working to help her better self-manage her hypertension and, in case of another CVA, to get her to hospital sooner. Grateful to MLH’s care for her without insurance, she wants a better life for herself, her niece and grandson.’

Annualized data comparing CHN members from 2011 to 2012 (when work began in 38109) shows a drop in Hospital Readmission Rate for any reason from 24.24% to 18.18%, and a drop in DRG Readmission Rate for heart failure from 18.18% to an astounding 2.27% (>90% reduction).